A Responsibility Deeper Than Family

Jan 12, 2021

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Tonya Craig is a critical care charge nurse at Gallup Indian Medical Center in New Mexico, a facility on the border of the Navajo Nation, which spans 27,000 square miles across three states (Arizona, New Mexico and Utah). The Navajo Nation — where many homes have no running water, electricity or telephones — has experienced over 23,000 COVID-19 cases. Navajo Nation President Jonathan Nez says that the tribe’s ICU beds are near capacity. For Craig, this global pandemic endangers her entire people and she feels a responsibility to her patients that is deeper than family.

How did you come into nursing?

I am Navajo. I grew up in Utah. I came back to the Navajo Nation during high school. I married my high school sweetheart. We've been together 30 years and have four children. I wanted to go into nursing as soon as I graduated but the program nearby had closed. Then I had three little boys 18 months apart, so I was a stay-at-home mom until they went to school.

At that time, I had been out of school for quite a bit, and I owe it to my mom because she kicked my butt and made me reapply. I told her I was very scared because I had been out so long and she was relentless. That was like shooting for the moon to me. I had always looked on nurses as such a noble, awesome profession. I was really surprised that I made it, because when I first went back to school, I couldn't remember how to do fractions.

I think that’s a huge challenge. I admire you for doing that.

It all came back to me, and thank goodness because I got back into the program, graduated from nursing school, and applied to my first job on a med-surg unit. My med-surg experience was awesome. I was paired with a long-term contract nurse. She really guided and encouraged me. I went on to an internal medicine clinic for a year. Then I wanted something a little bit more challenging since my kids were in high school and I had a lot of time. I applied to the intensive care unit and that was the greatest experience that I have had in my career, and I just love it. I found home, that's where I belong.

Can you tell us about the impact of COVID-19 on your work?

When we first started getting ready and heard about COVID cases, it seemed distant. We're a rural hospital, so we don't have the resources bigger hospitals have. We pulled together, put in our ideas on how we can do this. How can we make more beds? Where can we put patients?

Once we got those patients, it was like being a brand-new nurse because these patients did not follow anything like an ARDS patient. It seemed like you would be able to help with one thing when something else went wrong, and you didn't know why. Everything was different and it impacted a lot of us. It was a stressful, emotional time, and for us, our ICU family, we had to come together as a team.

That's an important experience to share.

There was nothing to fall back on — no studies, everything was anecdotal at that point. The moment we got off, even though we were super tired, all of us ICU nurses were on the internet reading anything, everything that we possibly could. What are the benefits? What else can we possibly do? Should we try this? Everybody was just in this moment.

For a while, it seemed to be all up in the air, and every day you came in you didn't know what would happen. At the end of the day, you were so thankful and emotional that it was like, “Okay, I got through this day; one more.” I know multiple times after work, I would drive home — and my drive home isn't that far — and sit outside in my vehicle and think about everything I did that day and about my patients. All of these questions inside your head. You call [fellow nurses] in the middle of the night and say, I forgot to tell you I did this. And I’d sit outside for another 30 minutes to try and put my mom face on, and be there for my parents, my husband and my daughter. It was a struggle.

It's an extremely hard day to come home from.

Yes, it was. I spoke to one of the other nurses and I got a little emotional. One of the male nurses came in — tough guy and we always go to him for things — and he asked, "Are you okay?" I tried to laugh it off. Then he got quiet and choked up. He said, "I went home after working with one of the Grandmothers [Editor’s note: Grandmother is a term of respect for older females in Navajo and other Native American cultures] and as soon as I got in the car I started crying." That’s when I knew that this is such a huge emotional time for all of us. Everybody felt that deep down in their soul.

As an ICU family, we came together. As a lead clinical nurse, I felt it was my duty to go to everybody and say, “We're having a hard time. It's very emotional. If you need to talk to somebody here are the resources, call this number.” I told them, "I'm not ashamed to say I had to call and speak to somebody and get these things straight in my head. That really helped me along. I needed it and I did not know I needed it. Just do it once or twice. It’s important.”

Tell us more about your experience with the evolution of the pandemic.

We saw a lot more patients with COVID in April and May. Our hospital has a partnership with the Brigham and Women's Hospital [Boston], so we were able to get a lot of guidance from what was happening out there, since we're only a six-bed ICU. Our hospital is a level three trauma center, and the nearest level one trauma center is 143 miles away.

Our facility, Gallup Indian Medical Center, is the hub for all of the outlying, more rural hospitals. We have more resources than they do, but at the same time we were getting a lot of critical patients. Most of the time we were full, and we were sending a lot of our patients to tertiary care centers in Albuquerque. We started feeling a little more confident in what we were doing, looking ahead, looking at the patient and trying to anticipate when that patient needs a higher level of care.

I don't want to say that we're well-versed in everything because with this whole pandemic, and with this virus, there are unknowns, and it’s surging again. I think the evolution of our COVID response is that we're feeling more confident than at the beginning.

With that little bit of experience, we can take that and give great care to our patients coming in. Here, at Gallup Indian Medical Center, most of our nurses are not just invested in the community, but as native Americans — as Navajo, as Zuni and all the different Native Tribes here — this is something deeper than even a responsibility to our family. We feel this responsibility to them on such a deep level. It's a feeling that we're all intertwined. I'll give you an example.

I was caring for an elderly lady. She had just recovered from COVID, was still on high-level oxygen and barely starting to eat. She was getting stronger and was finally able to speak without getting hypoxic. She noticed my last name on my badge, which is not a typical Navajo name. She asked, "Are you related to Nancy Craig?" And I said, "That's my nali, my father’s mother." Then she said, "Oh, her and I were best friends in high school.” She knew several of my family members. We were also connected by our Navajo clans. We don't call our patients Mr. or Mrs. Our respectful terms here are Grandma, Grandpa. It's such a deep responsibility that’s intrinsic to us as Native American, Navajo people, and to be advocates for our patients.

Your hospital has both a responsibility as a referral center for some hospitals and for sending patients to other facilities, is that right?

Yes. There are some nearby smaller hospitals that don't have the resources or specialties that we have. We also send patients to Albuquerque, which is almost 150 miles away. We don't have ground critical care transport or ambulance transport to Albuquerque, so our flight team here is crucial to getting patients to and from our facility. Being so rural and being a reference center, it’s vital that we have all of these different types of resources available to us.

Are you using proning as a strategy for patients?

Yes. As critical care nurses, we had always wanted to try proning. It was slowly coming into play and then COVID hit. We got a crash course in proning, and it was like, boom, bang, here's the video, let's get all of our doctors, RTs and nursing on board. We've been doing it all along now. We don't have nice, fancy proning beds, or the little adapters for the ventilators, but now we’re safe and have our team ready to act at any second. As a charge nurse, you must have an attitude of “We can do it.”

It sounds like you're a great team leader. I think that positive energy makes a big difference.

Oh, believe me it's hard. At home, I'm not usually so optimistic, but the moment I get here and put on my nurse face, you have to be able to jump in headfirst and know that your team is following you. And it’s important to tell them, “Thank you for coming in with me. I was scared, I was worried. You gave me strength.” Expressing gratitude really helps. As a house supervisor, going to the other floors and telling them: This is such a hard time, this is so scary, and you’re doing a great job. Thank you.” That's really important. Those little things are what we want to hear. And it's so surprising that some people will even get a little hitch in their throat. Sometimes you get a story, or you get that big deep breath and you know that they've been stressed and that they needed something, anything. And that's important for ourselves and it's important for our patients.

What healthcare disparities do you see and what message or call to action do you have for the community or other nurses?

I know the struggles that I feel here, I cannot begin to imagine the struggles that our outlying hospitals feel out there. We have two RTs for every shift for our whole hospital. And that's stretching them. They're hard workers and I applaud them. But at our outlying hospitals, some don't even have these specialties to help them care for patients. And I’m amazed at their ingenuity, strength and resilience.

They don't have the resources that I have. I am just amazed at what they're able to accomplish and how they're able to take care of our patients with the bare minimum of what is available to them. I don’t know if it's a call to action, but I would say that I wish people could see what we really do, and the toll this is taking on our patients.

There are people out there who don't have access to healthcare or it's inaccessible to them. In our less populated areas, it's two hours to get to a hospital. When we tell our older population that they need to go to a higher level of care, they say “I don't want to go, that's where they send you to die.” And that breaks my heart. It's such a struggle for them to get basic healthcare.

I feel grateful that the pandemic has brought attention to many struggles that the indigenous peoples — not just Navajo Nation, but other tribes and Native Americans — have with healthcare. As a nurse you feel this call to help people and it's so frustrating deep down inside that you can't go out there and help everybody and do the things that need to be done.

It's hard when the need overwhelms the resources. I appreciate your perspective on it and how you focus on gratitude.

I feel very grateful because it reminds me of why I want to be a nurse. In nursing school, we wrote out a mission statement of why we wanted to be a nurse, what we wanted to accomplish. My instructor said, "Please save this paper and look at it every five or 10 years. Put it with your important papers and when you come across it, see the beginning and see how much you've accomplished." I came across it a couple years back, and it gave me more purpose for what I am doing and for who I am.